III. Medical Insurance:

IV. Primary Doctor:

Name: *

Phone Number *

V. Dentist:

Name: *

Phone Number *

VI. Emergency Care Information and Consent to Enroll

I certify that I fully understand the general rules of C&T Youth Technology Academy (CTYTA) and I agree to obey such rules. In case of an emergency, CTYTA has my permission to take my child to the emergency room of the nearest hospital if I cannot be contacted, and the hospital staff has my authorization to provide treatment that a physician deems necessary for the wellbeing of my child. I, for myself, my heirs, personal representatives, or assigns, do hereby release, waive, and discharge CTYTA, its officers, directors, employees, and agents from liability from any and all claims, including but not limited to, physical or mental injury, illness, death, and property loss arising, from participation in activities of CTYTA.